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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601178
Report Date: 03/12/2025
Date Signed: 03/12/2025 12:13:18 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/21/2025 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250121124939
FACILITY NAME:OAKMONT OF BURLINGAMEFACILITY NUMBER:
415601178
ADMINISTRATOR:JANNA O'SULLIVANFACILITY TYPE:
740
ADDRESS:1818 TROUSDALE DRIVETELEPHONE:
(650) 692-2805
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:97CENSUS: 64DATE:
03/12/2025
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator, Janna O'SullivanTIME COMPLETED:
12:25 PM
ALLEGATION(S):
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Resident was locked in a room due to staff neglect
INVESTIGATION FINDINGS:
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On March 12, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced complaint visit to deliver the investigation outcome. LPA met with the administrator and explained the purpose to today's visit.

Regarding to the allegation of – resident was locked in a room due to staff neglect, the reporting party stated that resident – in – question (R1) resides on the memory care unit and the responsible party was notified by the facility that R1 was missing. The reporting party reported that after hours of searching, R1 was found in an empty room that was locked, and facility staff was not able to check that room because the door lock was broken. The reporting party also stated that the empty room was next to R1's room and he/she wandered into that room, shut the door and was not able to get out due to the broken lock. The reporting party stated that the facility did not search room to room resulting R1 being stuck in an empty room for hours.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 14-AS-20250121124939
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: OAKMONT OF BURLINGAME
FACILITY NUMBER: 415601178
VISIT DATE: 03/12/2025
NARRATIVE
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As part of the investigation, LPA interviewed the administrator, the maintenance director, and the resident care coordinator.

According to the administrator, she was notified at 5pm that R1 was missing, the facility immediately conducted a search inside and outside of the facility, viewed the camera footage, reported it to the local police department where a silver alert was activated, and reported it to R1’s responsible party. The administrator stated that R1 was found in a locked empty room that was next to R1’s room and the room was being prepared by the maintenance staff for new admission. The administrator stated that when a room is being prepared for new admissions, it should be closed when it’s not being worked on to avoid residents entering it. The administrator acknowledged that R1 would have been found a lot sooner had the staff search all the rooms on the 3rd floor.

LPA interviewed the maintenance director who stated that the day prior to the incident, he was getting the room ready for new admission and after painting the room, he realized that the door lock was broken but it was too late to bring it to the shop and fix it, so he left it open instead of closing it. According to the maintenance director, this was not endorsed to facility staff resulting staff was unaware that the empty room was open and R1 wandered inside, shut the door as the room was next to R1's room.

LPA interviewed the resident care coordinator who validated the information above and stated that R1 has a tendency of shutting the door after entering his/he room. Therefore, R1 mistakenly entered the empty room, shut the door and was not able to open it back up because of the broken lock.

Based on the documents provided by the facility, the Elopement /Missing Resident Policy 404 indicated that upon the discovery that a resident is thought to be missing, community team members will activate and follow the Missing Resident- Immediate Action Plan Form 405a and on the Form 405a, it indicated that within 5-10 minutes, assign staff to search unit.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Citations on this Visit Report are Under Appeal!

Control Number 14-AS-20250121124939
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: OAKMONT OF BURLINGAME
FACILITY NUMBER: 415601178
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
03/13/2025
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable...This requirement is not met as evidenced by based on interviews, record reviews and observations,
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The administrator/Licensee will provide a plan to prevent this from happening again and the plan shall include staff training. The administrator/licensee will provide a copy of the plan to CCL by 3/13/2025.
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staff did not follow the facility's missing resident search protocol to search all the rooms/units when R1 was discovered missing and staff was unaware of a broken door lock resulting R1 being in a locked empty room for hours which poses an immediately health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 14-AS-20250121124939
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: OAKMONT OF BURLINGAME
FACILITY NUMBER: 415601178
VISIT DATE: 03/12/2025
NARRATIVE
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After the investigation, this allegation is substantiated as the staff did not followed the protocols on the Action Plan Form 405a and search the unit/room on the floor and the director failed to endorse to staff that the empty room was left open resulting R1 being locked in a room with a broken door for many hours.

Based on interviews, and observations during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation was determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed with the administrator; a copy is provided with Appeal Rights provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4